Quality of Care

Under 483.25, each resident must receive and the facility must provide “the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the resident’s comprehensive assessment and plan of care.”

Among the specific components, the facility shall ensure (a) that the resident's ability to perform activities of daily living do not diminish, unless unavoidable, and those who cannot carry out those activities receive necessary services to maintain good nutrition, grooming, and personal oral hygiene;  (b) residents receive proper treatment and assistive devices to maintain vision and hearing, and assistance with necessary appointments and transportation to see specialists in these fields; (c) that a resident who is admitted without pressure sores does not develop them unless it is unavoidable, and a resident with pressure sores receives the necessary treatment to promote healing, prevent infections, and new sores; (d) that a resident admitted without a urinary catheter not receive one unless it is unavoidable, and that residents who are incontinent of bladder receive services to prevent urinary infections and restore as much bladder function as possible; (e) that residents who are admitted without limited range of motion do not experience reductions in range of motion unless unavoidable, and that resident with a limited range of motion receive treatment to increase those abilities and prevent further deterioration; (f) that residents who displays mental or psychosocial adjustment difficulties receive appropriate treatment to correct the assessed problem, and that a resident whose initial assessment did not reveal such a problem does not show decreased social interaction or increased withdrawn, angry, or depressive behaviors, unless such deterioration was deemed unavoidable because of the clinical condition; (g) that a resident admitted without a nasogastric feeding tube not be fed through such a tube, unless deemed necessary, and that a resident with a feeding tube receive appropriate treatment and services to prevent aspiration pneumonia, vomiting, dehydration, metabolic disorders, and nasal-pharyngeal ulcers, and that afford be mode to restore normal feeding skills; (h) that the environment be as free of hazards as possible, and each resident receives supervision and assistive devices so as to prevent accidents; (i) that the resident maintain acceptable parameters of nutrition status such as body weight and protein levels, unless his or her physical condition makes that impossible, and that the resident receives a therapeutic diet when it is indicated; and (j) that the resident receive sufficient fluids to maintain hydration and health.  Each of these regulations follows a similar pattern: first, stating that if the resident is admitted without a particular problem, he or she should not develop it unless the clinical condition makes it unavoidable; but that if the resident has or develops the problem, the treatment should prevent complications and attempt to restore the original function.

In addition, the residents should (k) receive proper treatment for special needs and services, which include: injections; parenteral and enteral fluids; colostomy, ureterostomy, or ileostomy care; tracheostomy care; tracheal suctioning; respiratory care; foot care; and prostheses. 

Under (l), the resident should be free of unnecessary drugs, defined as excessive doses, excessive duration, drugs not indicated, or drugs with adverse consequences.  If residents are admitted without antipsychotic drugs, they should not be started unless necessary to treat a specific condition, and residents who receive antipsychotic drugs should receive gradual reductions and behavioral therapy in an effort to discontinue those drugs.  Under (m), the facility must ensure that the resident be free of medication errors, and that the medication error rate in the facility be 5% or less. 

Comparison of State Requirements  [TOP]
 

Quality of Care standards, as outlined in the Federal regulations, include only what might be termed “the basics” that really apply to everyone, whether a nursing home resident or not:  Bathing, grooming, eating, drinking, toileting, walking (and other movement), accident prevention, and minimum standards to maintain physical health (catheter, tube and ostomy cares; monitoring for infection; over-medication prevention).   States with a more comprehensive approach and/or a wider scope than the Federal regulations require tend to focus on the nursing procedures that support the delivery of quality care (Idaho, Wyoming).

Trends specific to this category are not yet apparent, as they are not reflected statutorily or, in many cases, as their own category.  Much of what encompasses a “total” concept of Quality of Care is reflected in or derived from other regulatory categories, such as Nursing Services, Dietary Services, and Resident Rights.

[Summarized: April 2006]

Table Comparing States  [TOP]

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Administration by State (with a link to each State's specific language).  Link to a downloadable PDF containing  all State regulation on Administration is at the bottom of the Table.
 

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Complete Transcript of State Regulations on Quality of Care